Friday, September 25, 2009

Sometimes, Small Steps Get You There Faster...

Jay Cost at RealClearPolitics offers a great analysis of the political stakes involved in health care reform.

From Cost: "In this country, it is highly inadvisable for political leaders to pass such sweeping reforms absent a consensus that is both broad and deep. Such a consensus simply does not exist on this issue. If the President and Democratic leaders move forward with their plans anyway - despite these plainly and clearly expressed doubts - they risk reaping the whirlwind."

This lesson was learned all to well in Australia as they spent decades enacting and repealing and revising highly partisan health refrom endeavors. We do not want to repeat that here, not on an issue this important.

More from Cost: "It does not have to be this way. If the President would narrow the scope of these overly ambitious reforms, it is likely that he could formulate a broad legislative consensus on changes to the health care system. "

This bit of advice from Cost may be an especially bitter pill to swallow, especially among those of us who study health policy and understand how desperately we need substantial reform. But if the public does not accept the legitimacy of the reform, if the public rejects what is ultimately passed, the result would be a set back that would likely keep health reform off of the agenda for at least another 15 years.

And there is no reason to view a narrower piece of legislation as a defeat. In 1960, when many advocated universal health care for the elderly, partisan forces in Congress compromised and created "Medical Assistance for the Aged." It was by no means universal; rather it was a means-tested grant program that provided federal funds to states that chose to cover "medically needy" elderly individuals (essentially low income individuals in need of assistance for medical expenses).

Many viewed this program to be woefully insufficient - and it was - after 5 years only 29 states participated and they offered very limited services. But in American public policy we rarely construct fundamental new policies; rather we like to build off of existing policies. In 1965, using Medical Assistance for the Aged as a foundation, Congress created Medicare - a universal and mandatory health program for the aged, and Medicaid - a state/federal means-tested program that provides health care for low income children, pregnant women, and some low income elderly. Thirty years later Medicaid served as a model to create the State Children’s Health Insurance Program (SCHIP) to further extend health coverage for near poor children and pregnant women.

Today, over 100 million Americans receive their health care from Medicare, Medicaid, or SCHIP - one-third of the nation. The lesson of Medical Assistance for the Aged is that sometimes, a series of small steps can get you to a destination more effectively than a risky leap. At this point, trying to enact substantial health reform without firm public support, without any consensus in Congress, and via parliamentary tricks like reconciliation would be a very risky leap and could ultimately do more to harm reform efforts than help.

My advice to President Obama and the Democratic leadership is simple: Compromise, lay the foundation, and then start building...